The Price of Health: When Doctors Chase Miracles - A special report.; Costs and Hope Battle in Intensive Care Units

By ERIK ECKHOLM

Published: December 22, 1991

The first of November, five days after a car accident broke nearly every bone in his body, the Rev. Clair Frederick Yohe, 87 years old, lay semiconscious in the surgical intensive care unit of the Albany Medical Center.

Given his advanced age, the multitude of broken bones, the collapsed lung and the lacerated internal organs, doctors had known from the start that he had scant chance of surviving. Yet every one of his injuries could in theory be fixed, and his brain was intact. So the doctors and nurses were doing everything they could, and doing it well.

Over and over they wheeled him to the operating room to sew up bleeding organs and repair shattered bones. They ran tubes into his neck, chest and arms to feed him oxygen, nutrients, antibiotics and sedatives, to drain fluid from his chest and take constant readings of his heart function and other vital signs. They put his legs in traction and wired his cracked jaw shut. Where Dilemmas Meet

Through it all Mr. Yohe lay still, the gentle seashore rhythms of his mechanical breather belying the violence of his injuries, the furiousness of his care.

As the country's health costs climb there is serious talk about rationing of high-priced care like this, of avoiding treatment that is unlikely to succeed. And it is in the intensive care unit, with patients like Mr. Yohe, where all the financial, technological and ethical dilemmas converge.

On another floor of the Albany hospital, in the medical intensive care unit, 51-year-old Kathleen Cookingham also lay unconscious, her breath supplied by the mechanical ventilator that defines life in the I.C.U. More than a year earlier, with her body already ravaged by advancing multiple sclerosis, Mrs. Cookingham, her husband and her doctors had all agreed that that no heroic resuscitations should be attempted. Yet now she had been in intensive care for more than three months, with no end in sight.

"When Kathy decided that she would not live on a machine, I had the impression it was a black and white issue," her husband, Earl Cookingham, later said. "It was never that. It was a very gradual type of thing. You made this decision and that decision, and all of a sudden you're where you didn't want to be."

That same November day, Sheryl Dugan, a 28-year-old mother of four, was happily tending her children at home in Morris, N.Y. Earlier this year she too had lain critically ill in an Albany intensive care unit, even giving emergency birth to a daughter there. A runaway lung infection had put her so near death that her doctors gave up hope. But she recovered miraculously, becoming a vibrant example of why extraordinary measures are pursued at all.

Care of the critically ill, applying the highest technology to the sickest patients, is startlingly expensive, by some estimates consuming close to 1 percent of the gross national product. As the ability to sustain failing bodies gets ever better, the potential costs become virtually limitless. In the end, the way that society chooses to care for patients like Mr. Yohe, Mrs. Cookingham and Mrs. Dugan will set the outer limits of the country's medical spending.

It will help define society's ethical limits, too. "We have to make sure we are prolonging life, not just prolonging the dying process," said Dr. I. Alan Fein, head of surgical critical care at Albany Medical Center and one of the doctors attending Mr. Yohe.

The spreading "right to die" movement, asserting the right of fatally stricken patients to forego futile care, will certainly help hold down costs and allow more peaceful deaths. On the other side, fear of legal action, or the insistence of families that cling to groundless hopes, sometimes prevents doctors from withholding care they know will be useless.

But even when the patient, the family and the doctor are all attuned, there is often no obvious answer, as the stories of these three patients show. "Doctors can't decide these things," said Dr. Thomas C. Smith, chief of Albany's medical I.C.U. "Society has to tell us what to do." Trauma Patient No Half Measures For Critically Hurt

Except for arthritis, Mr. Yohe (pronounced YO-hee) and his wife, Louise, 81, were the picture of health. For 60 years he had served as a Methodist minister, most of them in partnership with Louise, his wife of 54 years. For the last two decades the couple lived on Isle LaMotte, on Lake Champlain in Vermont, where they raised their own pesticide-free vegetables.

It was an interim ministry in the late 1960's, when they helped get a small-town church on its feet, that led the Yohes to be driving one Sunday last October near Kingston, N.Y., some 60 miles south of Albany. A still-grateful congregation had asked Mr. Yohe back to participate in a service and share recollections.

After the service, they were on their way to join a family for lunch, Mrs. Yohe driving their Geo, when another car plowed into theirs. Mrs. Yohe's right leg, pelvis and ribs were injured. Her husband was, as she bluntly describes it, "shattered."

Help came quickly, and the pair were taken to the nearby Kingston hospital. Because Mr. Yohe's injuries were so serious, doctors there sent him by ambulance to Albany, the advanced regional medical center. Traveling on a ventilator, he arrived at the Albany emergency room in deep shock, his blood pressure barely perceptible. Transfusions and More Transfusions

The emergency room doctors did what they are supposed to do when a critically ill patient arrives: they started aggressive treatment. And once treatment began, there could be no going halfway. The transfusions began immediately, and over the next 48 hours Mr. Yohe's entire blood volume would be replaced more than three times. He was rushed to the operating room, where his damaged spleen was removed and his stomach and kidneys were sewn up; over the next two weeks he would repeatedly be taken from the intensive care unit to the operating room for elaborate repairs of the badly broken bones in both arms, his upper and lower legs and his face.

The day after the accident, still in great pain herself but informed that her husband was in grave danger, Mrs. Yohe was wheeled to his bedside. "He was highly sedated and didn't arouse," she later recalled. But when she came back the next day, "he lifted a couple fingers, as if in a greeting," she said. "So I gather that he knew me."

And later, after his jaw had been wired shut, "I was telling him a little about what had happened," she said. "I think he had a faint smile, and that gave me hope, of course.

"I told the doctors I wanted to know the truth about his condition," she recalled. "I had a little premonition that I wouldn't take him home alive. I must tell you, though, my husband was a fighter." The 'Umpteenth' Operation

About two weeks after the accident, Dr. Fein would tell a caller: "He's still hanging in there, going back for his umpteenth orthopedic procedure. The odds of him actually surviving are incredibly slim. But theoretically everything is reversible. So we just trudge along and see what happens."

At about that point Mr. Yohe's lungs began functioning well enough to wean him from the ventilator. No longer in need of such minute-by-minute, one-on-one scrutiny, he was transferred to a normal hospital room, freeing up the scarce intensive care bed he had occupied for two and a half weeks.

But as expected he was still in perilous condition, his liver and kidneys declining under the cumulative strain, hospital-acquired infections setting in. The doctors told Mrs. Yohe how ill her husband was, but said they could keep him alive on a dialysis machine. "I said no, we didn't want that," she recalled. "We had decided a long time ago that neither one of us wanted to be on life support. "I had to sign a form, and that was very hard.

"I wasn't surprised when the doctor came to my room," Mrs. Yohe said of the visit she received on Nov. 23, while still in the hospital herself for physical therapy. "They told me that he just went to sleep." Reassessment Deciding to Give Long Odds a Shot

If marginal care is ever to be rationed, patients in Mr. Yohe's condition might be among the first to be denied aggressive treatment. When he entered the Albany hospital, doctors believed, based on intuition and experience, that he had less than a 1 percent chance of surviving.

While the hospital has not yet totaled the bills for his final month, they were certainly more than $100,000, Dr. Fein said. Hospital costs are relatively low in upstate New York, and billing is limited by state regulation; in many parts of the country, or in New York City, his care might have cost several times that. In his case, auto insurance and Medicare should cover most of the fees.

Had Mrs. Yohe insisted on continued aggressive treatment, as some relatives in similar circumstances do, her husband might have been sustained on a dialysis machine and a ventilator for another month or more, his doctors believe, at several thousand dollars a day.

Several medical teams around the country are developing "prognostic scales," score cards for judging survival odds of the critically ill. Their goal is a tool that can help doctors avoid useless care. For patients in a lasting coma, or who are certainly about to die from, for example, widespread cancer, the futility can be obvious. In such cases, I.C.U. directors already, without a numerical score card, often serve as gatekeeper, refusing entry into their crowded units of patients who can die elsewhere more comfortably, with less cost.

But refusing care is never easy, even at a hospital like Albany, where doctors are in the forefront of thinking about prudent use of medical technology, even with patients like Mr. Yohe who have declared a desire to avoid prolonged misery.

"We believed he had only a 1 percent chance of survival, and yet we admitted him," Dr. Fein said, several days after Mr. Yohe's death. "Was that the right thing to have done? Probably it was.

He added, "Society still has very high expectations of what we should do for a patient like Reverend Yohe." Revolving Door Patient Machine's Chains Form Link by Link

Sometimes medical care can build in a series of individually sensible steps to a senseless extreme, with no obvious cutoff point along the way.

Over the last four years Kathleen Cook ingham, a mother of two daughters now 19 and 24, became what doctors sometimes call a "revolving door" patient in the I.C.U., in and out repeatedly with no hope of a cure and a declining quality of life. Mrs. Cookingham had worked as a legal secretary until 1985, when multiple sclerosis, a progressive deterioration of the nervous system, had seriously impaired her eyes, legs and bladder.

The disease worsened in 1987, and she had to enter the hospital for intensive care. That stay lasted four agonizing months. She was unconscious at times, and the doctors said they did not believe she would survive.

"She fought, and she came out of the hospital," her husband, Earl, recently recalled. "She was in a wheelchair, but she led a productive life." But she and her husband vowed that she would avoid a miserable life on machines. To See Her Daughter Wed

Over the next three years, her condition deteriorating, she required several more hospital stays, some for a few days, some for weeks, usually requiring intensive care and mechanical breathing, especially as the multiple sclerosis affected nerves that controlled her diaphragm.

Another crisis occurred in December 1990. By then, she had also lost control of her swallowing muscles, which meant she would have to be fed indefinitely through a stomach tube, just the kind of dependence she had hoped to avoid. The Cookinghams, who live on the outskirts of Albany, had developed a close relationship with hospital doctors, and the husband called Dr. Smith, a pulmonary and critical-care specialist, to discuss what to do. "The question was whether we should just leave her at home and let her die," Mr. Cookingham said.

Even then, Dr. Smith recalls, it was clear that her treatment was pushing beyond what anyone wanted. But their older daughter's wedding was just days away. As Dr. Smith remembers it, "Her husband beseeched us to keep her alive another three days, to not let her die before her daughter's wedding." As Mr. Cookingham describes it, Dr. Smith told him, "You can't deal with this now; bring her to the hospital."

So she spent weeks in the I.C.U., and her chronic care escalated another unwanted step. She went home in January, a stomach tube in place; now she needed a full-time nurse. But that spring, she was able to see her second daughter graduate from high school.

A spate of seizures required several visits to the emergency room and then, last July, another hospitalization. A chest infection forced her back onto a ventilator. The weeks in the I.C.U. went by and then still another technological step was taken. 'We Don't Have to Keep Going'

Because she never wanted to be on a breathing machine more than temporarily, Mrs. Cookingham had always refused to have a tracheostomy, in which a tube is put through the neck directly to the windpipe. Though to her it symbolized unwanted medical bondage, a tracheostomy is safer and less uncomfortable than a tube down the throat, the short-term approach.

This last stay in the I.C.U. dragged on so long, her husband said, that it seemed cruel to leave a throat tube in, so he finally consented to the tracheostomy. But soon after that she developed a blood infection, and "things really began to go sour," he said.

By early November Mrs. Cookingham's condition was worse than ever. Dr. Smith, emotionally drained himself, convinced that her care had spun out of control, decided to broach the unthinkable with her husband.

"I told him we don't have to keep going," Dr. Smith recalled.

"Kathy and I had agreed that if the ventilation was only temporary that was fine," Mr. Cookingham later said. "But then it got to be two, three months." He remembers that the doctor showed him pictures of her scarred lungs and explained that her heart was now impaired. She had stopped communicating. "That's when we decided to take her off the machine," Mr. Cookingham said. "I was following her wishes."

A few days later, Nov. 7, a priest joined the family in the intensive care unit and held a Catholic service at her bedside. "We all went in and held hands," Dr. Smith said. The service took about 20 minutes. Dr. Smith then gave her morphine and removed her breathing tube. Twenty minutes later she was dead. Reassessment Putting a Price On 2 Good Years

Thinking over the last few years, Mr. Cook ingham, at least, said he would not have done much differently. "She was so unpredictable," he said. "The doctors repeatedly said she wouldn't come off the machine, and then she did, and came home and had a decent life." In hindsight, he said, "maybe the last month went on longer than we intended."

Her final three-month stay in intensive care cost at least $180,000, the doctors estimate, and her care over the last several years cost several hundred thousand dollars. (In some regions the costs would have surpassed $1 million.)

The Cookinghams themselves did not have to pay much. The bills were mainly paid with public money -- by Medicare, which covers disabled people, supplemented by their private policy. Medicaid paid for a home nurse over much of the last year.

"It was worth it," Mr. Cookingham said. "I know that's easy for me to say, because financially it didn't kill us, but I think it was worth it." The rounds of costly intensive care "gave her three years to live, three years with us, and two of the three years were very good."

Dr. Smith is still visibly seared. "The language isn't good enough to convey the emotions going on with a case like this," he said. "It's like the Eskimos having all those different words for snow. We don't yet have the right vocabulary for dying." Miracle Patient The Hopeless Case That Affirms Hope

The I.C.U. doctors do not give up on any patient without thinking about Sheryl Dugan, a patient who they thought would surely die, but somehow walked out of the hospital on her own feet. She was in her eighth month of pregnancy last May when her three children -- boys now four and three, a girl of 18 months -- came down with chicken pox. Then she did too. Routine for children, chicken pox is potentially disastrous for pregnant women, who often suffer severe complications.

Mrs. Dugan's doctor warned her to go to the hospital at the first sign of a cough, and one night the coughing started. Doctors at the nearest hospital, in Oneonta, N.Y., found that the chicken pox virus, which had already caused scratchy sores all over her body, had spread into her lungs, and sent her by ambulance on the two-hour trip to Albany.

She arrived at the Albany Medical Center early on June 1, and later that day, her pneumonia worsening by the minute, was put into intensive care and on a ventilator.

The chicken pox virus had spread not only through her lungs but also her liver, causing hepatitis. On top of that, a potentially lethal bacterium had invaded her weakened lungs, and she developed a blood infection. Her bowel shut down and she became anemic. Most dangerous of all, she developed adult respiratory distress syndrome, an untreatable, often fatal response to infections in which fluids leak uncontrollably into the lung tissue, impeding the ability to absorb oxygen.

On her second day in the intensive care unit Mrs. Dugan went into labor. "It was pretty hectic, with about 25 people in a 10 by 15 room," her husband recalled. Woozy from drugs and disease, Mrs. Dugan nevertheless remembers the birth quite clearly. "They didn't want me to push," she said. "They were afraid my lungs might burst. But I helped anyway." She would remember nothing more of the next four weeks.

The baby girl cried when she emerged and was rushed away to prevent further exposure to the chicken pox. Near Despair, Then a Change

Doctors fought Mrs. Dugan's infections with antibiotics and the chicken pox with an antiviral drug, but mostly they could do little more than wait. To force more oxygen through her damaged lungs, the ventilator was turned up full throttle, risking a fatal tear of tissue from the high air pressure. She had to be paralyzed because even one cough, against that pressure, "would have shattered her lungs," Dr. Smith said. Even so, Mrs. Dugan was absorbing so little oxygen that her heart began stopping intermittently, at one point failing to beat for six full seconds. Her tissues accumulated fluids, raising her weight from her normal 130 pounds to more than 200.

The baby, at the age of 10 days, was in fine shape and was sent home to Mrs. Dugan's sister. "That was pretty tough seeing her go," said Mr. Dugan, who would spend a month at his wife's bedside, from 7 in the morning to 10 at night. "I thought if Sheryl could see the baby that might help her fight back."

On June 19th, Mr. Dugan recalled, "I called Sheryl's name and she didn't respond at all. That's when I realized things were pretty serious."

That day, doctors convened a conference with the family, the hospital's pastoral care unit, social workers and nurses. "They told me she wasn't going to make it," Mr. Dugan recalled. He went for a long walk, found a church and sat.

"We would have quit," Dr. Smith later said, "except here you had a 27-year-old with a new baby."

Then suddenly, only a couple of days after that painful family conference, and for no apparent reason, something changed. "After a while you get to know the machines," her husband said. "I saw the numbers coming round. She opened her eyes and looked around a bit, and she started to recognize my voice again."

Her recovery was as swift as her decline. Doctors began weaning her from the mechanical breather on June 29. The next day is when she remembers fully waking up. "I didn't even know why I was there," she says. "The nurses talked to me like they knew me, but I didn't recognize them."

A few days later, July 5, her breathing tube was removed. She left for home on July 8, the more than $50,000 devoted to her care well spent. As she left, the doctors and nurses cried.

"She got better so fast, I believe in miracles," Dr. Smith would later say.

Photos: As health costs rise, there is talk of rationing high-priced care. Sheryl Dugan, holding her daughter Kelly, contracted a serious lung infection while pregnant and was treated in intensive care, the medical arena where issues of finance, technology and ethics collide. (Jeff Serowick for The New York Times); Kathleen Cookingham, in a family photo with her daughter Kristin in 1987, had multiple sclerosis and became what doctors sometimes call a "revolving door" patient: in and out repeatedly with no hope of a cure and a declining quality of life.; The Rev. Clair Frederick Yohe, left, was kept alive after being given little chance for survival after a car accident, and needed a dialysis machine to stay alive. "I said no, we didn't want that," said his wife, Louise. They had agreed long ago that neither wanted to be on life support. "I had to sign a form, and that was very hard," she said. (Paul O. Boisvert for The New York Times) (pg. 24)